NCS000057 DMR SW (2)

STORMWATER DISCHARGE OUTFALL (SDO)
MONITORING REPORT
Permit Number NCS O U O O .5-7 SAMPLES COLLECTED DURING CALENDAR YEAR: Lqn i �y—
FACILITY NAME'-j6-
AMEhn(
PERSON COLLEC G SAMPLE(S) P64t`=
CERTIFIED LABORATORY(S) PAC _Lab # /
Lab #
Part A: Specific Monitoring Requirements
(This monitoring report shall be received by the Division no later than 30 days from
the date the facility receives the sampling results from the laboratory.)
COUNTY CT�44';� �_LS
PHONE NO. (7®Y) .5:T- / 7 %
SIGNATURE OF PERMITTEE OR DESIGNEE
REQUIRED ON PAGE 2.
Does this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? _ yes
(if yes, complete Part B)
Part B: Vehicle Maintenance Arfivity "A
Outfall , . ' Date
,'Date11 1
I;
it
00530,
46,406",
No: Sampler. `
- Collected
;Total Flow .
if a
( pplicable)
,Total
Rainfall
.
Oil & Grease:
,(ifappl.)y;
_
-1Von-polar:: ?
;�O&G/TPH
`(Method 1664
S.GT�HEJf
.Total`;: x
SuSpeRded>r=�„�`�
Solids'!
H `
>p,•
�.'
,NwMotor
Oil•`Usa e
g
a ib/dd/ r
MG .
=inches
m
a 1.
m 1`'
>,
`unit -
aUmo
Does this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? _ yes
(if yes, complete Part B)
Part B: Vehicle Maintenance Arfivity "A
Outfall , . ' Date
50050
00556
00530,
46,406",
No: Sampler. `
- Collected
;Total Flow .
if a
( pplicable)
,Total
Rainfall
.
Oil & Grease:
,(ifappl.)y;
_
-1Von-polar:: ?
;�O&G/TPH
`(Method 1664
S.GT�HEJf
.Total`;: x
SuSpeRded>r=�„�`�
Solids'!
H `
>p,•
�.'
,NwMotor
Oil•`Usa e
g
a ib/dd/ r
MG .
=inches
m
a 1.
m 1`'
>,
`unit -
aUmo
Form SWU-247, last revised 2/2/2012
Pagel of 2

STORM EVENT, CHARACTERISTICS_: Mail Original and'one.copy�to: ;
' o? %' owl S. on of Water Quality ti Y:
-
-Date/0 ..- _ ' .. - Divisi
:' ! Attn: Central Files'
Total EV' Precipitation (inches): f, � �- � - = � ,- ' - 1617.Mai1'Service Center
Event Duration (hours): (only if applicable — see permit.) - Raleigh, North Carolina'276 -1617 `
99.
(if more than'one storm event was sampled)_
Date - -
Total Event Precipitation (inches):
-Event Duration (hours): (only if applicable — see permit-) • _ I .�
IN
"I certify, under penalty of law; that this•document and all attachments were prepared under my direction'or1supervision in accordance with a..;
_ system designed to assure that qualified personnel properly gather and evaluate.the•information submitted. Based on my.inquiry"of the person:_', `' ~
or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the'. T
best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting~false inform_ ati_6ii
including the possibility of fines and -imprisonment for knowing violations." I
(Signature of Permittee), '.-(Date)- --
,.
Z. `
Form SW`U-247; last revised 2/2/2012
_ _ Page 2 of 2 '